Plan For _____________ (Student) Dated: _______________
DIABETES MEDICAL MANAGEMENT PLAN
I.
CONTACT AND PLAN INFORMATION
Student’s Name: ____________________________ Date of Birth: _______/____/______
(Month) (Day) (Year)
Health Condition:
Diabetes type 1
Diabetes type 2 (For this Plan “Health Condition”
means diabetes)
Mother/Guardian: _____________________________________________________________
Address: _____________________________________________________________________
Telephone: Home __________________ Work _________________ Cell_________________
Father/Guardian: _____________________________________________________________
Address: _____________________________________________________________________
Telephone: Home _________________ Work __________________ Cell _________________
Student’s Doctor/Health Care Provider:___________________________________________
Address: _____________________________________________________________________
Telephone: ________________________ Emergency Number: __________________________
Other Emergency Contacts:______________________________________________________
Relationship: __________________________________________________________________
Telephone: Home _________________ Work _________________ Cell __________________
II. PARENT OR GUARDIAN
AUTHORIZATION, APPROVAL AND LIABILITY WAIVER
The parents or guardians (hereinafter “Parent”) request that Minden Public Schools allow the Student to selfmanage the health condition and accept and agree to this Medical Management Plan. The Guidelines for
Diabetes Medical Management Plan are incorporated into and are a part of this Plan.
Parents understand and agree that if the Student injures school personnel or another student as the result of
the misuse of necessary diabetes medical supplies, Parents shall be responsible for any and all costs
associated with such injury. Parents acknowledge that (a) the school and its employees and agents are not
liable for any injury or death arising from the Student’s self-management of the Student’s Health Condition
and Parents release same from any such claims and (b) Parents shall and do hereby agree to indemnify and
hold harmless the school and its employees and agents against any claim arising from the Student’s selfmanagement of Student’s Health Condition. This release, indemnification and hold harmless agreement shall
take effect immediately and shall stay in effect for as long as the Student is provided permission to selfadminister medication.
Parent/guardian signature: ___________________________________ Date: ______________
Parent/guardian signature: ___________________________________ Date: ______________
III. STUDENT AGREEMENT
I will use the prescription diabetes medication only as prescribed and as permitted by the Plan. I will
not share the medication with others and I will not create an unnecessary distraction to others. I have
been instructed how to self-administer this medication and understand the side effects of improper use
and will follow the Guidelines. I understand that if I do not abide by these terms, I may be disciplined
and that this Plan will be re-evaluated. I release the school and its employees of any liability any in way
related to this Plan or my use of the medication.
Student signature: __________________________________________ Date: ____________
DIABETES MEDICAL MANAGEMENT PLAN FOR _______________________________
(Student)
Page 2 of 6
Dated: _______________
IV. MEDICAL MANAGEMENT PLAN
A. Health care services the Student may receive at school relating to Student’s Health
Condition: See Guidelines (Part V).
B.
Evaluation of Student’s understanding of and ability to self-manage Student’s Health
Condition.
The parents/guardians and the Physician certify that the Student has a sufficient level of
understanding and ability to self-manage the Student’s Health Condition as follows:
1. Access to Prescription Diabetes Medication
□ May have medication in Student’s possession at any time.
□
□
May have medication in Student’s possession when the health office is not accessible
(for example, when the Student is out of the school on field trips or participating in
extracurricular activities) but should otherwise be maintained in the health office.
May not have medication in Student’s possession except for emergency use.
2. Self-Administration of Prescription Diabetes Medication
□ May self-administer independently and without supervision. The Student has had had
training and is proficient in self-administering medication.
□ May self-administer when the health office or school staff authorized to administer
medication are not readily accessible (for example, when the Student is out of the
school on field trips or participating in extracurricular activities); but should otherwise
have medication administered by the health office or authorized school staff.
□ May not self-administer except for emergency use.
C.
It is agreed that this Plan permits regular monitoring of Student’s self-management of
Student’s Health Condition by an appropriately credentialed health care professional.
D.
Name, purpose and dosage of prescription diabetes medication prescribed for Student:
See Student Diabetes Action Plan (Part IV(F)).
E.
Procedures for storage and access to backup supplies of such prescription medication for
Student’s Health Condition:
1. The Student, when permitted to be in possession of medication, will only have the
prescription medication that might be needed for the Student’s own use.
2. The school will store any backup supply needed in accordance with its medication storage
procedures.
3. The student may have access to the backup supply when necessary by requesting such from
the health office.
DIABETES MEDICAL MANAGEMENT PLAN FOR _______________________________
(Student)
Page 3 of 6
Dated: _______________
Student Diabetes Action Plan
F.
Student Name: _____________________________________
Date of Birth: _______/____/______
(Month) (Day) (Year)
EXERCISE PRECAUTION - Should not exercise (eg, gym class, recess) if blood glucose level is
below_________mg/dl or if moderate to large urine ketones are present
SUPPLIES TO BE CARRIED BY THE STUDENT
“USE” DESCRIBES PURPOSE, WHEN TO USE & AS RELEVANT,
DOSAGE
Use: _______________________________________________________
□ Blood glucose meter, blood glucose test strips, batteries for meter
Use: _______________________________________________________
□ Lancet device, lancets, gloves, etc.
Use: _______________________________________________________
□Urine ketone strips
Use: _______________________________________________________
□Insulin pump and supplies
Use: _______________________________________________________
□Insulin pen, pen needles, insulin cartridges
Use: _______________________________________________________
□Fast-acting source of glucose
Use: _______________________________________________________
□Carbohydrate containing snack
Use: _______________________________________________________
□Continuous Glucose Monitor
Use: _______________________________________________________
□ May carry and self-administer above medications and supplies per Part IV(B) of
Medical Management Plan.
Possible adverse reactions to be reported to physician __________________________________________
_____________________________________________________________________________________
Special instructions _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I am the Student’s Physician. Student has diabetes and has been prescribed the medication referenced
above. Student has the ability to safely and responsibly self-manage Student’s Health Condition in
accordance with this Diabetes Medical Management Plan. I approve the Medical Management Plan and the
Student Diabetes Action Plan and authorize Student to self-manage Student’s Health Condition at school in
accordance with the Plan.
Physician signature: ____________________________________________ Date: ___________
DIABETES MEDICAL MANAGEMENT PLAN FOR _______________________________
Dated: _______________
(Student)
Page 4 of 6
V. GUIDELINES FOR
DIABETES MEDICAL MANAGEMENT PLAN
Term of Plan: The plan is effective for the current school year. A new plan must be established
each school year or more often if changes occur to the student’s health or prescribed treatment or
student’s ability to self-manage.
Medications: The parents or guardians are responsible for supplying any and all prescription
diabetes medications required under the Plan; the school is not responsible for providing the
medications. Prescribed diabetes medications to be used by the Student under this Plan must be
furnished in a current original container from the pharmacy with the student's name and the name
of the medication, and where applicable, the strength and the dosage to be given. If the prescribed
medication, dosage or time of medication changes, the parents or guardians must promptly submit
to the school nurse or designee the new prescription and as necessary a new diabetes action plan.
Any non-prescription medication must be furnished in the original container from the manufacturer.
The school will store any backup supply needed in accordance with its medication storage
procedures. The student may have access to the backup supply when necessary by requesting such
from the health office.
Disposal of Medical Supplies: The student shall be responsible for proper disposal of used
syringes and other medical supplies. Used syringes and blood borne pathogen materials shall be
immediately placed in a safe receptacle and properly disposed of in accordance with directions of
the school health office and school administration.
Health care services the Student may receive at school relating to Student’s Health Condition.
1. Standard health services available to all students.
2. Storage of backup diabetes medication supplies.
3. Individual Health Plan (IHP) for diabetes management may be developed on request.
Consultations: The school may consult with a registered nurse or other health care professional
employed by such school during development of the plan.
Permitted Self-Management: Pursuant to the Diabetes Medical Management Plan the Student
shall be permitted to self-manage the Student’s diabetes condition in the classroom or any part of
the school or on school grounds, during any school-related activity, or in any private location
specified in the plan.
Student Reports of Self-Administration: The Student is not required to report self-administration
when the Student has self-administered prescription diabetes medication pursuant to the Plan. The
school health office will maintain a log of self-administration reports upon request of the parent or
guardian.
Responses to Student Misuse: The possession of medications by Students is a violation of the
school’s drug and student conduct policies and may result in an expulsion from school. To the
extent this Diabetes Medical Management Plan permits the Student to be in possession of
prescribed diabetes medications, the Plan allows the Student an exception to the school drug and
student conduct policies. However, this exception only extends to the extent provided in the Plan.
In the event the Student uses his or her prescription diabetes medication other than as prescribed, or
possesses medication other than as permitted by the Plan, the Student is subject to disciplinary
action by the school, up to and including an expulsion. The school will promptly notify the parent
or guardian of any disciplinary action imposed. The disciplinary action will not include a limitation
or restriction on the student’s access to such medication unless the school determines that the
Student has endangered himself, herself, or others through the misuse or threatened misuse of such
medical supplies. It is agreed that in the event of any such misuse a re-evaluation of the Student’s
understanding of and ability to self-manage Student’s Health Condition will occur and the reevaluation may result in a modification or termination of this Plan.
DIABETES MEDICAL MANAGEMENT PLAN FOR _______________________________
(Student)
Dated: _______________
Page 5 of 6
Sharing Plan: It is agreed that this Diabetes Medical Management Plan may be shared with school
officials and agents who have a need to be aware of it; that those who have the need to be aware of
it include student health staff and also include staff responsible for student discipline (e.g. staff
need to know that the Student is authorized to have the medication on the Student’s person so the
Student is not reported for a violation of the school’s drug policies). The school officials who may
be informed of the Plan thus include: administration, school nurse, school office staff, teachers and
any paraeducators or specialists who provide services to the Student, and the coaches and sponsors
of extracurricular activities in which the Student participates.
Filing of Plan: This Diabetes Medical Management Plan is to be kept on file at the school where
the Student is enrolled.
VI. SCHOOL NURSE ACKNOWLEDGEMENT OF
DIABETES MEDICAL MANAGEMENT PLAN
□ Parent Request and Liability Waiver signed □ Student Agreement signed.
□ Management Plan (including Action Plan) signed by Physician.
□ Guidelines reviewed with the Student and Parent/Guardian.
□ Copy of Guidelines and Student Agreement received by Parent/Guardian for reference.
School Nurse or designee signature: ________________________________________ Date: ___________
DIABETES MEDICAL MANAGEMENT PLAN FOR _______________________________
(Student)
Page 6 of 6
Dated: _______________
Diabetes Self-Management Log (Optional)
Student Name__________________________________________
Student Date of Birth ______________________
Date Started
Date/time of
report
Medication
Date/time
administration
Dosage
Time
Frequency
Observation/Complications
Physician
Employee
Recording
Student Report
Phone #
Parent Notification
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Date:___________
Phone
Form
Parents/Guardian____________________ Phone________________
Teacher_________________________
Grade________